Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=80 BGCOLOR="#000000" TEXT="#F7F7FF" bgproperties="fixed" background="images/04000500dvldtc.gif"> <div> <B>Cremation Society of </B><I><B>Virginia </B></I><B>~ Tidewater Office</B></div> <div> <B> </B><A HREF="id72.htm" TARGET="_top" TITLE="Site Index"><U><B>Site Index</B></U></A><B>   |   </B><A HREF="id17.htm" TARGET="_top" TITLE="About Us"><U><B>About Us</B></U></A><B>   |   </B><A HREF="id19.htm" TARGET="_top" TITLE="Price Information"><U><B>Price Information</B></U></A><B>   |   </B><B>Registration Form</B><B>   |   </B><A HREF="id27.htm" TARGET="_top" TITLE="Q As / Benefits"><U><B>Q & As /  Benefits</B></U></A><B>   |   </B><A HREF="id50.htm" TARGET="_top" TITLE="Educational Programs"><U><B>Educational Programs</B></U></A><B>   |   </B><A HREF="id57.htm" TARGET="_top" TITLE="How to Write An Obituary"><U><B>How to Write An Obituary</B></U></A><B>   |   </B><A HREF="id84.htm" TARGET="_top" TITLE="Register Book"><U><B>Register Book</B></U></A><B>   |   </B><A HREF="id85.htm" TARGET="_top" TITLE="Cards Flowers"><U><B>Cards & Flowers</B></U></A><B>   |   </B><A HREF="id35.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#000000" TEXT="#F7F7FF" background="images/041d2c00dvldtc.gif"> <div> <A HREF="id72.htm" TARGET="_top" TITLE="Site Index"><U>Back to Site Index</U></A></div> <div> <IMG SRC="images/18dafa40.gif" border=0 ALIGN="BOTTOM" HSPACE="0" VSPACE="0" width="175" height="164"></div> <div> Cornerstone Granite</div> <div> $385.00</div> <div>  <a href="#" onclick="window.open('https://www.paypal.com/cart/add=1&business=twiford%40adelphia.net&item_name=Wilbert+Cornerstone+Granite&item_number=P331M&amount=385.00&return=http%3A//www.cremate.org&cancel_return=http%3A//www.cremate.org','cartwin','width=600,height=400,scrollbars,location,resizable,status');"><img src="http://images.paypal.com/images/sc-but-03.gif" border="0"></a>  </div> <div> <IMG SRC="images/18e64300.gif" border=0 ALIGN="BOTTOM" HSPACE="0" VSPACE="0" width="100" height="48"></div> </td> <td valign="top" height=400 BGCOLOR="#FFFBF0" TEXT="#080000"> <div> Registration Form </div> <div> <A HREF="id32_pre_pay.htm" TARGET="_top" TITLE="PrePlanning"><U><B>Back to Pre-Pay and Join</B></U></A></div> <div> <B>Complete the form below and then click payment.  $25.00 membership fee will be charged to your credit card.  We guarantee all credit card payments and guarantee the secure payment when credit cards are used.</B></div> <div> <B> <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <html><head> <title>Cremation Society of Virginia</title> </head> <body bgcolor="White" text="Black"> <table width="430" border="0" cellspacing="0" cellpadding="0"> <tr><td></td></tr></table> <p><table width="430" border="0" cellspacing="0" cellpadding="0"> <tr><td><font face="Arial,Helvetica"> <font SIZE="5">T</font>o become a member of the Cremation Society of Virginia, simply complete this form along with your credit card information. You are a member of the Cremation Society of Virginia when this form is received. Within a few days, you will receive your wallet-size membership ID card. Please note that the information on this form is kept strictly confidential.<br><br></p> <div align="center"><center> <font face="Arial,Helvetica" size="2"><b>Please Complete All Fields.</b><br>This information is required to complete the death certificate.<br>If you do not know the answer to a field, please enter "Unknown"</font><p></td></tr> <FORM action="mailto:info@cremate.org" method="post" enctype="text/plain"> <table width="430" border="0" cellspacing="0" cellpadding="0"> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Registrant:</b></font></td></tr> <tr> <td align="right">First Name</td> <td colspan="2"><input type="text" name="firstname" value="" size="30"></td> </tr><tr> <td align="right">Middle Name:</td> <td colspan="2"><input type="text" name="middlename" value="" size="30"></td> </tr><tr> <td align="right">Last Name:</td> <td colspan="2"><input type="text" name="lastname" value="" size="30"></td> </tr><tr> <td align="right">E-Mail:</td> <td colspan="2"><input type="text" name="email" value="" size="30"></td> </tr><tr> <td align="right">Street Address:</td> <td colspan="2"><input type="text" name="address" value="" size="30"></td> </tr><tr> <td align="right">Apt/Suite:</td> <td colspan="2"><input type="text" name="suite" value="" size="30"></td> </tr><tr> <td align="right">City:</td> <td colspan="2"><input type="text" name="city" value="" size="30"></td> </tr><tr> <td align="right">State:</td> <td colspan="2"><input type="text" name="state" value="" size="2"></td> </tr><tr> <td align="right">ZIP Code:</td> <td colspan="2"><input type="text" name="zip" value="" size="5" maxlength="5"> - <input type="text" name="zipplus4" value="" size="4" maxlength="4"></td> </tr><tr> <td align="right">City/County of Residence:</td> <td colspan="2"><input type="text" name="cityresidence" value="" size="13"> - <input type="text" name="countyresidence" value="" size="13"></td> </tr><tr> <td align="right">Social Security Number:</td> <td colspan="2"><input type="text" name="socialsecurity" value="" size="30"></td> </tr><tr> <td align="right">Date of Birth:</td> <td colspan="2"><input type="text" name="bdate" value="" size="30"></td> </tr><tr> <td align="right">State/Country of Birth:</td> <td colspan="2"><input type="text" name="bstate" value="" size="30"></td> </tr><tr> <td align="right">Telephone Number:</td> <td colspan="2"><input type="text" name="phone" value="" size="30"></td> </tr><tr> <td align="right">Citizen of what Country:</td> <td colspan="2"><input type="text" name="citizen" value="USA" size="30"></td> </tr><tr> <td align="right">Education (Years Completed):</td> <td colspan="2"><input type="text" name="education" value="" size="2"></td> </tr><tr> <td align="right">Registrants Last Occupation:</td> <td colspan="2"><input type="text" name="lastoccupation" value="" size="30"></td> </tr><tr> <td align="right">Industry of Last Occupation:</td> <td colspan="2"><input type="text" name="industryoccupation" value="" size="30"></td> </tr> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Spouse:</b></font></td></tr> <tr> <td align="right">First Name:</td> <td colspan="2"><input type="text" name="spousefirst" value="" size="30"></td> </tr><tr> <td align="right">Last/Maiden Name:</td> <td colspan="2"><input type="text" name="spouselast" value="" size="30"></td> </tr><tr> <td align="right"><font SIZE="3"> Check if deceased: </font> </td> <td colspan="2"><input TYPE="checkbox" NAME="spousedeceased" value="Yes"></td> </tr> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Father:</b></font></td></tr> <tr> <td align="right">First Name:</td> <td colspan="2"><input type="text" name="fatherfirst" value="" size="30"></td> </tr><tr> <td align="right">Last Name:</td> <td colspan="2"><input type="text" name="fatherlast" value="" size="30"></td> </tr><tr> <td align="right"><font SIZE="3"> Check if deceased: </font> </td> <td colspan="2"><input type="checkbox" name="fatherdeceased" value="Yes"></td> </tr> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Mother:</b></font></td></tr> <tr> <td align="right">First Name:</td> <td colspan="2"><input type="text" name="motherfirst" value="" size="30"></td> </tr><tr> <td align="right">Maiden Name:</td> <td colspan="2"><input type="text" name="motherlast" value="" size="30"></td> </tr><tr> <td align="right"><font SIZE="3"> Check if deceased: </font> </td> <td colspan="2"><input type="checkbox" name="motherdeceased" value="Yes"></td> </tr> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Military:</b></font></td></tr> <tr> <td align="right">Veteran</td> <td><input NAME="veteran" TYPE="radio" value="Yes"> Yes <input NAME="veteran" TYPE="radio" value="No"> No</td> </tr> <tr> <td align="right">Date of Entry :</td> <td colspan="2"><input type="text" name="veteranentry" value="" size="30"></td> </tr> <tr> <td align="right">Place of Entry :</td> <td colspan="2"><input type="text" name="veteranentryplace" value="" size="30"></td> </tr> <tr> <td align="right">Date of Discharge:</td> <td colspan="2"><input type="text" name="datedischarge" value="" size="30"></td> </tr> <tr> <td align="right">Place of Discharge:</td> <td colspan="2"><input type="text" name="placedischarge" value="" size="30"></td> </tr> <tr> <td align="right">Branch of Service:</td> <td colspan="2"><input type="text" name="branchservice" value="" size="30"></td> </tr> <tr> <td align="right">Serial Number:</td> <td colspan="2"><input type="text" name="serialnumber" value="" size="30"></td> </tr> <tr bgcolor="Black"><td colspan="3"><font face="Arial,Helvetica" size="2" color="White"><b>Next Of Kin:</b></font></td></tr> <tr> <td align="right">Name:</td> <td colspan="2"><input type="text" name="kinname" value="" size="30"></td> </tr><tr> <td align="right">Relationship:</td> <td colspan="2"><input type="text" name="relationship" value="" size="30"></td> </tr><tr> <td align="right">Street Address:</td> <td colspan="2"><input type="text" name="kinaddress" value="" size="30"></td> </tr><tr> <td align="right">Apt/Suite:</td> <td colspan="2"><input type="text" name="kinsuite" value="" size="30"></td> </tr><tr> <td align="right">City:</td> <td colspan="2"><input type="text" name="kincity" value="" size="30"></td> </tr><tr> <td align="right">State:</td> <td colspan="2"><input type="text" name="kinstate" value="" size="2"></td> </tr><tr> <td align="right">ZIP Code:</td> <td colspan="2"><input type="text" name="kinzip" value="" size="5" maxlength="5"></td> </tr><tr> <td align="right">Phone:</td> <td colspan="2"><input type="text" name="kinphone" value="" size="30"></td> </tr><tr><td colspan="2"> </td></tr> <font SIZE="5">B</font>y Typing my name below twice, I acknowledge and affirm that this will become a "Digital Signature" of my name and shall have the same effect as if I signed the form below. This form shall be considered a legal Authorization for Cremation and shall indicate my desire to have my body cremated.<br><br></p> <tr> <td align="right">Digital Signature:</td> <td colspan="2"><input type="text" name="digitialsignature" value="" size="30"></td> </tr><tr> <tr> <td align="right">Digital Signature:</td> <td colspan="2"><input type="text" name="digitialsignature" value="" size="30"></td> </tr><tr> </tr> <tr><td colspan="2"><div align="center"><center><input type="submit" name="action" value="SEND"></center></div></td></tr> </table><br> </form> </body> </html>  </B></div> <DIV ALIGN="LEFT"></DIV> <div> AUTHORIZATION FOR CUSTODY, CREMATION AND FINAL DISPOSITION</div> <div> By submitting this form, I hereby authorize and request the Cremation Society of Virginia, in accordance with its rules and regulations, and any applicable laws or regulations, to take possession of, to cremate and to carry out the final disposition of my remains as instructed above.</div> <DIV ALIGN="LEFT"></DIV> <div> <I>Press </I><I><B>Send</B></I><I> button on above form </I><I><B><U>AND</U></B></I><I> then press </I><I><B><U>"Add to Cart"</U></B></I><I> below to complete transaction.</I><I> </I> </div> <div>  <a href="#" onclick="window.open('https://www.paypal.com/cart/add=1&business=twiford%40adelphia.net&item_name=Membership+Fee&item_number=MM001&amount=25.00&return=http%3A//www.cremate.org&cancel_return=http%3A//www.cremate.org','cartwin','width=600,height=400,scrollbars,location,resizable,status');"><img src="http://images.paypal.com/images/sc-but-03.gif" border="0"></a>    <a href="#" onclick="window.open('https://www.paypal.com/cart/display=1&business=twiford%40adelphia.net','cartwin','width=600,height=400,scrollbars,location,resizable,status');"><img src="http://images.paypal.com/images/view_cart.gif" border="0"></a>  </div> <bR> <div>   <FONT SIZE="3" COLOR="#000000" FACE="Arial" >       </FONT></div> </td> </tr></table></body>